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Healthcare Fraud

This archive displays posts tagged as relevant to healthcare fraud.

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Watch: “Taking Advantage” Highlights Medicare Risk Adjustment Fraud

Posted  11/2/18
Constantine Cannon partner Mary Inman and two Constantine Cannon whistleblower clients are featured in Episode 3 of the PBS series “Playing by the Rules: Ethics at Work.” The episode investigates ”risk adjustment” in the Medicare Advantage program and practices by some of America’s largest insurance companies to make patients look sicker than they really are-which boosts payments to the insurance companies...

November 1, 2018

The CEO and COO of Smart Lab LLC have been sentenced to a cumulative 10 years in prison for defrauding TRICARE of millions of dollars. CEO H. Hamilton Wayne and COO Justin Morgan Wayne allegedly paid kickbacks to substance abuse treatment centers in exchange for using Smart Lab for expensive confirmatory urinalysis testing. In some cases, treatment center patients were required to submit three medically unnecessary samples a week, but exempt from paying co-payments, co-insurance, or deductibles that should've been mandatory. Altogether, they have been ordered to pay restitution amounting to $2,897,389.50. Separately, H. Wayne has been ordered to pay $104,344, and J. Wayne has been ordered to pay $20,000. A third defendant, Smart Lab sales representative Lanny Fried, remains to be sentenced later this month. USAO SDFL

October 31, 2018

A London-based doctor has been sentenced to 42 months in federal prison for defrauding Medicare, Medicaid, and private insurers. The doctor, Dr. Anis Chalhoub, was convicted in April of implanting over 200 medically unnecessary pacemakers in patients at St. Joseph London hospital, reportedly even pressuring patients and giving them misleading information so that they would agree to the procedures. He is ordered to pay $257,515 in restitution to Medicare, Medicaid, and private insurers, as well as a $50,000 fine. USAO EDKY

October 30, 2018

Four people connected to a Texas-based home health agency have been found guilty of fraudulently obtaining $3.7 million in reimbursements from Medicare and Medicaid. Despite being previously banned from participating in any federal healthcare reimbursement programs, Celestine Okwilagwe and Paul Emordi co-owned and operated a Medicare and Medicaid provider in the Dallas area called Elder Care. Adetutu Etti, the provider's administrator, was recruited to falsely certify that someone else was the owner, and Okwilagwe's wife, Loveth Isidaehomen, was recruited to sign checks. Some of the claims that were eventually reimbursed by Medicare were also found to be for services that were not medically necessary. DOJ

“Widespread and Persistent” Problems in Medicare Managed Care Burden Patients and Are Potential Violations of the False Claims Act

Posted  10/30/18
The federal government’s internal watchdog for the Medicare and Medicaid healthcare programs, the U.S. Department of Health and Human Services Office of the Inspector General (OIG), has issued a report finding that Medicare Advantage Organizations (MAOs) have engaged in a “widespread and persistent” practice of inappropriately denying coverage for medical services to Medicare patientsIn addition, OIG has...

October 24, 2018

The owners and operators of two community mental health clinics in Pennsylvania and North Carolina have entered into a $3 million consent judgment with the United States to resolve allegations of violating the False Claims Act. In 2000, Melchor Martinez was convicted of Medicaid fraud by the State of Pennsylvania and subsequently banned from owning and operating health clinics or seeking reimbursement from all federally funded healthcare programs. Despite this, he allegedly continued to own and operate three chains of mental health clinics—including Northeast Community Health Centers, Lehigh Valley Community Mental Health Centers, and Carolina Community Mental Health Centers—by enlisting the help of his wife, Melissa Chlebowski, to act as the true owner and operator. In addition, the two allegedly failed to operate according to rules set by Medicare and Medicaid, including seeing patients for only 2-3 minutes and billing for 15, and billing for services provided by unqualified staff. They were eventually outed in a qui tam lawsuit filed by a former employee. USAO EDPA

October 23, 2018

Eye Centers of Florida, owned by Dr. David C. Brown, has agreed to pay $525,000 to settle claims of that it knowingly falsified the medical records of certain Medicare patients in order to submit qualifying reimbursement claims. In violation of the False Claims Act, Eye Centers allegedly altered the paperwork to make it appear that patients had worse vision than they actually did, allowing Eye Centers to bill for cataract surgeries that would ordinarily not have been reimbursable. The case was revealed through a lawsuit filed by two former employees, Patti Nilsson and Joann Smith, who are set to receive $115,500 from the settlement. USAO MDFL

October 23, 2018

Vascular Access Centers LP (VAC) and its 20+ related corporations in multiple states have agreed to pay $3.825 million over five years to settle whistleblower-brought allegations that VAC took part in an illegal patient referral kickback scheme and fraudulently billed Medicare for certain non-reimbursable procedures. The alleged fraud violated the Anti-Kickback Statute and False Claims Act and involved regularly scheduling, performing, and billing Medicare for certain vascular access procedures for End Stage Renal Disease (ESRD) beneficiaries that were not routinely necessary. Two whistleblowers will share in the relator's share of $612,000. DOJ; USAO EDLA; USAO SDNY

October 18, 2018

Dr. Felmor Agatep, a Florida-based doctor, has plead guilty to receiving kickbacks and defrauding TRICARE over prescriptions to outrageously expensive and medically unnecessary pain and scar creams. According to the DOJ press release, a one month supply of the creams in question cost more than $16,000 when made by a compounding pharmacy. At some point in late 2014, Agatep agreed to receive kickbacks from a marketing group of $100 per TRICARE patient in exchange for writing prescriptions for these creams. In just a month and a half, Agatep allegedly wrote a total of 265 prescriptions, which amounted to a bill of $4.4 million for TRICARE. He now faces a maximum penalty of 10 years in prison. USAO MDFL

Healthcare Fraud: it’s not just Medicare and Medicaid

Posted  10/17/18
topical cream spilled out
Last year, the U.S. Department of Justice recovered $2.4 billion in settlements and judgments involving fraud in the healthcare industry perpetrated against government payors. But government programs like Medicare and Medicaid aren’t the only targets of massive healthcare fraud schemes. A recent Department of Justice press release announced the unsealing of a 32-count indictment containing charges against four...
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